Regaining Weight in a Healthy Way

Reprinted from Eating Disorders Recovery Today
An Interview with C. Wayne Callaway, MD
Winter 2002 Volume 1, Number 2
©2002 Gürze Books

Regaining weight can be a very frustrating process for persons with anorexia nervosa. Often what looks like weight gain turns out to be fluid retention, or edema. (Edema is swelling of any part of the body due to collection of fluid in the spaces between the cells.) We talked with Dr. Wayne Callaway, a well-known endocrinologist and eating disorders expert in Washington, DC, to see what one can do about regaining weight safely and comfortably.

Eating Disorders Today: Dr. Callaway, why is the process of regaining weight so frustrating for some patients?

Dr. Callaway: It can be difficult because many factors are involved, including the unseen physiologic processes that can work against the patient. The more a person understands about what is happening, the more independent he or she can become, and the more successful weight regain will be.

EDT: What does happen when a patient regains weight?

Dr. Callaway: First, it's important to remember that day-to-day measurements on the scale nearly always reflect water weight, and the number on a scale should not be used as the only guide. Generally, when people have severely cut back on their food intake and/or have been exercising excessively, their resting metabolic rates will fall. They can do nothing about this; it is programmed in the genes to allow one to survive famine or lack of food. When food is restricted, less thyroid hormone is converted into the active form, triiodothyronine, or T3, and the sympathetic nervous system slows down; this involves norepinephrine (a hormone secreted by the adrenal glands) and dopamine (a neurotransmitter essential for normal nerve activity). Then metabolism slows. This is very helpful for survival, but also causes blood pressure and pulse rate to fall. As a result, the small blood vessels don't constrict as well when one sits or stands. This is one of the reasons that some people faint when they are restricting food intake.

EDT: Is there any way to predict who will have problems with edema when they start refeeding?

Dr. Callaway: If a person has a pulse rate of 60 or less or her blood pressure is under 100/60, or even 110/70, if her hands are cold, and she has slowed reflexes, these are all pretty good signs that she will retain fluid as she begins to eat more, particularly if she eats more carbohydrates. With increased carbohydrates, the body is forced to produce more insulin, which causes the kidneys to retain salt and water. It also increases the permeability, or "leakiness," of the capillaries. Patients will still have low blood pressure when they sit or stand. The heart pumps harder because it is pushing more fluid out, too.

EDT: What do you do in your practice?

Dr. Callaway: First the patient and I discuss what is happening physiologically, and during the physical exam I show her that she has edema or slow reflexes. Often these persons will have bluish fingertips and slowed deep tendon reflexes. I explain that since her metabolic rate is low, the best and healthiest way for her to regain weight is to first identify the underlying physiologic things that are going on. I explain the biology of what is happening behind the scenes. It may be a little scary at first to talk about these things, but most patients can stay with the program if they know that the water weight gain will pass. If a person has a very low metabolic rate, I work with a nutritionist try to increase food in small increments. Sometimes this is as little as 100 calories a week, then we go to 200-calorie per week, until the level gets back up to something that is midway between what a person should be burning at rest and with activity.

EDT: What can a person do about fluid retention?

Dr. Callaway: We suggest that patients try to keep the amount of fat in their diets at the daily amounts recommended in standard dietary guidelines, or up to about 30% of daily intake. When fluid retention is a problem during the recovery phase, it doesn't hurt for a patient to get 35% or even more of their calories as fat. Most anorexic patients don't want to eat fat, but if they try to bring their metabolic rate up with carbohydrates, the carbohydrates will cause increased insulin secretion, which will only exaggerate the edema. I also suggest trying to limit simple sugars; they are high in carbohydrates, which can be every easily absorbed and require a surge in insulin, which makes the whole problem of fluid retention worse. One type of complex carbohydrates, those that contain beta-glucan insoluble fiber, slows the absorption of sugar. Also, there is nothing wrong with eating eggs. It's also important to try to establish an eating pattern where you get enough food at each meal and thus don't crave food between meals.

EDT: Some patients complain about regaining weight right in the abdomen. What can they do?

Dr. Callaway: If they are getting lots of calories during refeeding, most of the calories are going to end up right in the abdomen because there is also a large release of steroids, which makes the insulin level go up, and this gets stored as fat in the abdomen. My goal for patients like these is to allow them to build back their muscle tissue, and to some extent their fat storage as well, while bringing their metabolic rate up.

EDT: How can family members help?

Dr. Callaway: The most important thing family members can do is not to be policemen. Sometimes fathers are worse than mothers in this regard. The goal of therapy should be to rewrite the story for that person. I deal with the physiological part, and tell patients that their therapy will be much more successful if they can focus on the areas that are really important in terms of understanding behavior and dealing with individual issues. But I also tell them that it is going to be very difficult if there is a biological part that can sabotage efforts to regain weight.

EDT: And what if the patient skips or delays a meal?

Dr. Callaway: My patients know that if something happens and they delay a meal or under-eat a meal or skip a meal, it is a one-time event. The mistake gives them a roadmap to go by, to get back on track. It is like this in business, sports, and politics as well. The person who learns from the experience, not the person who blames the experience for his or her failure the rest of her or his life, is much more likely to succeed over the long term.

About The Author

C. Wayne Callaway, MD, is an endocrinologist, eating disorders specialist, and Associate Clinical Professor of Medicine at George Washington University, all in Washington, DC. Dr. Callaway is also a well-known author and speaker and a leader in global nutrition and public health.